When a husband takes out his work frustrations and anger by abusing his wife at home, the nurse will identify this crisis as which type?
-
Solution
Dispositional crisis
A dispositional crisis is a response to an external situational crisis. External anger at work is the dispositional crisis displaced to his wife through abuse.
Option A: Psychiatric emergency crisis is when the individual’s general functioning has been severely impaired, and the individual has been rendered incompetent.
Option B: Developmental crisis occurs in response to triggering emotions related to unresolved conflict in one’s life. This is called a developmental crisis based on Freudian psychology.
Option C: An anticipated life transition crisis is a crisis that is normal in the life cycle; transitional is one over which the person has no control.
A student nurse is caring for a 75-year-old client who is very confused. The student’s communication tools should include:
-
Solution
Gentle touch while guiding ADLs (activities of daily living).
Nonverbal, gentle touch is an important tool here. Providing appropriate forms of touch to reinforce caring feelings. Because tactile contacts vary considerably among individuals, families, and cultures, the nurse must be sensitive to the differences in attitudes and practices of clients and self.
A nurse is teaching a stress-management program for a client. Which of the following beliefs will the nurse advocate as a method of coping with stressful life events?
-
Solution
Control over one’s response to stress is possible.
When learning to manage stress, it is helpful to believe that one has the ability to control one’s response to stress.
Option A: It is impossible to avoid stress, which is a normal experience.
Options C and D: Stress can be positive and growth enhancing as well as harmful. The belief that one has some control can minimize the stress response.
The nurse is caring for a severely depressed client who has just been admitted to the in-client psychiatric unit. Which of the following is a PRIORITY of care?
-
Solution
Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan.
A client with paranoid thoughts refuses to eat because he believes the food has poisoned. The MOST appropriate initial action is to
-
Solution
Simply state the food is not poisoned
This action presents reality.
The nurse can BEST ensure the safety of a demented client who wanders from the room by
-
Solution
Attaching a wander guard sensor band to the client’s wrist
This type of identification band easily tracks the client’s movements and ensures safety while wandering on the unit.
A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from other clients. Which of the following would be the MOST appropriate statement by the nurse to promote interaction with other clients?
-
Solution
“Come play Chinese Checkers with Gerry and me.”
This gradually engages the client in interactions with others and uses positive behavioral expectation.
When planning the therapeutic milieu, it is MOST important to select group activities which
-
Solution
Achieve clients’ therapeutic goals
Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, e.g., to minimize withdrawal and regression, to develop self-care skills, etc.
Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?
-
Solution
“You look upset. Would you like to talk about it?”
Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific or focused on being therapeutic.
Which statement by the client during the initial assessment in the emergency department is most indicative of suspected domestic violence?
-
Solution
“I have tried leaving, but have always gone back.”
Victims develop a high tolerance for abuse. They blame themselves for being victimized. All members of the family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often have an extensive history of abuse and struggle for a long time before they can leave permanently.